MEDICARE: DR. KIN CHO WONG DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	1223P0221X	Pediatric Dentistry	102461	CA

General Provider Information

NPI Number	:	1477902112
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KIN CHO WONG DDS

Provider Business Mailing Address
First Line	:	223 N ELECTRIC AVE
Second Line	:
City	:	ALHAMBRA
State	:	CA
Zip	:	91801-1929
Country	:	US
Telephone Number	:	626-300-8223
Fax Number	:

Provider Business Practice Location Address
First Line	:	1041 E YORBA LINDA BLVD STE 206
Second Line	:
City	:	PLACENTIA
State	:	CA
Zip	:	92870-3763
Country	:	US
Telephone Number	:	714-528-8252
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/03/2016
Last Update Date	:	11/02/2020

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